Breathing - give what? - what to assess? 4 -what to recognize & treat?

1- high flow oxygen 2- assess chest - inspection- breathing spontaneous - palpation and feeling of trachea- trachea not deviated, chest rise equal, chest spring negative, no crepitus, no chest wall trauma - percussion- percussion resonant - auscultation-lungs clear air entry equal 3- recognise and treat ATOM-FC

Circulation What to assess? - inspect - palpation 8 - auscultation

Assess circulation Inspect: -looking for external hemorrhage or active bleeding Palpation: - skin color, temperature & capillary refill - pelvic spring - abdominal trauma - pulse - blood pressure - neck veins Auscultation: muffled heart sound

Where does blood collect? 4 potential spaces where fluid collects Morison’s pouch - blood in RUQ - hepatorenal recess (Morison's pouch) between liver and right kidney, will also flow into right paracolic gutter into pelvis blood in LUQ - often between diaphragm and spleen, will also flow into splenorenal recess, then into left paracolic gutter into pelvis Subdiaphragmatic - blood in LUQ, // the phrenocolic ligament often shunts fluid to Morison's pouch before filling the left paracolic gutter Pericardial - blood around heart Posterior cul de sac - blood in pelvis; rectovesical or rectouterine pouch, then into paracolic gutters

Myhow Flashcards by deena khairiah

Rapid primary survey

Airway
Breathing
Cirulation
Disability
Exposure/ environmental control

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Airway & cervical spine control

Initial mx
1- assess? 5
2- create and maintain airway? 5
3- position

1- assess airway patency

speak in full sentences
no foreign body ij object
no facial injuries
no cervical tenderness & full ROM
c-collar on

2- create or maintain airway by

looking with suction
chin lift or jaw thrust
naso/oropharyngeal airway
orotracheal intubation
cricothyroidectomy

3- check for cervical spine injury
-maintain spine in safe neutral position (c-collar) until clinical exam and radio findings exclude injury

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Breathing

give what?
what to assess? 4

-what to recognize & treat?

1- high flow oxygen

2- assess chest

inspection- breathing spontaneous
palpation and feeling of trachea- trachea not deviated, chest rise equal, chest spring negative, no crepitus, no chest wall trauma
percussion- percussion resonant
auscultation-lungs clear air entry equal

3- recognise and treat ATOM-FC

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ATOM-FC

Airway obstruction or disruption
Tension pneumothorax
Open pneumothorax
Massive pneumothorax
Flail chest
Cardiac tamponade

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Disability?
-
-
-
-

1- GCS & DXT

2- pupillary size and response

3- examine lateralising sign and signs of cord injury

4- moving all four limbs?

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Circulation

What to assess?

inspect
palpation 8
auscultation

Assess circulation

Inspect:
-looking for external hemorrhage or active bleeding

Palpation:

skin color, temperature & capillary refill
pelvic spring
abdominal trauma
pulse
blood pressure
neck veins

Auscultation: muffled heart sound

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5 N

Noggin- raccoon eyes, Battle’s sign

Neck- C spine, neurogenic shock, nuchal ridgidity

eNt- otorrhea, rhinorrhea, tongue biting, hemortympanum

Needles- iv drug abuser

Neurological- GCS, posture, movement, pupils, reflexes, corneal reflex, gag reflex, doll’s eye reflex, oculovestibular reflex

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Airway maintenance with C-spine control

airway normal? Compromised?
cervical spine- normal? Suspect injury?

1) airway patency
- NORMAL breathing/speech
- Compromised: stridor, cyanosis
2) Cervical Spine
- NORMAL: non tender, ROM full - Suspect Injury: tender

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Breathing and ventilation

Vitals: SpO2, RR

NORMAL: spontaneous
Compromised: stridor, unequal chest rise

Inspection: trachea deviation, chest rise, flail chest
Palpation: chest spring, crepitus/emphysema
Auscultation - normal breath sound/Crepts/Silent Chest?
Percussion - resonant/hyperresonant/dull

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Intervention- breathing

head tilt-chin lift / jaw thrust
remove foreign body by sweeping - O2 mask
oropharyngeal airway + bag
Intubation
-protect C spine with collar

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Circulation

Pulses, hemorrhage control

Vitals: HR, BP / CRT, peripheries warm?

Inspection: active bleeding/bruises/open wound
Palpation: pelvic spring/PA tender
Ausc: muffled heart sounds
Perc: PA dullness

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Intervention- circulation

2 large bore branula
FBC/RP/VBG/Coagulation/RBS
IV fluids
Hemorrhage control- compression bandage/tourniquet

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Disability

Neurologic status

Vitals: DXT
1) GCS: EVM
2) Pupils equal/reactive to light?
3) Gross Motor fn: Limbs – movement / deformity
4) Spinal injury? priapism, loss of anal sphincter tone/ bulbocavernosus reflex

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Exposure and environment

Vitals: Temperature
1) Remove clothes, inspect for wounds

2) warm blanket and saline

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Intervention- environment control & exposure

Cover with blanket

- Analgesic

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Adjuncts

1- Log roll

2- FAST scan

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Intervention- disability

Hypoglycemia: Dextrose 50% 50cc stat + IVD D10%
Seizure control: midazolam 5-10mg IV, followed by phenytoin 18mg/kg IV over 30 minutes
Fracture: immobilization/splint
GCS

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Log roll

A) Involves at least 3 person:
Stabilize head + pelvis + limbs
- turn body together at the count of 3, turn away form injured limb

B) Examine back
- check for bruises/open wound
- check for spinal tenderness/step deformity
- PR – anal tone, high riding prostate (in semi-conscious pt, CBD tug can elicit anal tone –BCR-bulbocavernous reflex)

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FAST exam

Where does blood collect?

4 potential spaces where fluid collects

Morison’s pouch - blood in RUQ - hepatorenal recess (Morison’s pouch) between liver and right kidney, will also flow into right paracolic gutter into pelvis blood in LUQ - often between diaphragm and spleen, will also flow into splenorenal recess, then into left paracolic gutter into pelvis
Subdiaphragmatic - blood in LUQ, // the phrenocolic ligament often shunts fluid to Morison’s pouch before filling the left paracolic gutter
Pericardial - blood around heart
Posterior cul de sac - blood in pelvis; rectovesical or rectouterine pouch, then into paracolic gutters

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Secondary survey

Head

Scalp: laceration
Skull: depression/basal #
face: L/w or #, midface or maxilla instability eyes: Orbit/globe/eyelid injury
ears: haemotympanum, CSF leak
nose: bleeding
Mouth: Tooth #

Neck - C spine injury, soft tissues (larynx)

Chest
- chest wall injury, # ribs, flail chest, open Pneumothorax, emphysema, Haemothorax, pulmonary contusion

Abdomen
- skin contusion/abrasion, distension, tenderness, guarding PR: lax anal tone, blood, high prostate

PV: injury/bleed

Perineum : blood at urethra, hematuria

Extremities: limb fractures/deformities

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ATOM FC 2

Aortic dissection

Thorax injuries
(non-massive haemothorax, simple pneumothorax),

Oesphageal perforation,

Muscular diaphragmatic injury,

Fistula (bronchopleural) and other tracheobronchial injury

Contusion to the heart or lungs

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Rapid sequence intubation 9P’s

1) Preparation
- Yourself: PPE-Mask, apron, gloves, - Your team
- Equipment
2) Preoxygenation
- HFM 15L/min for 3-5mins
3) Position
- sniffing position, flex neck, extend head
4) Premedication
IV Fentanyl 3mcg/kg
IV Lignocaine Lidocaine 1.5mg/kg
5) Put to sleep (Induction agent)
IV Etomidate 0.3mg/kg IV Ketamine 1-4.5mg/kg IV Propofol 2-2.5mg/kg IV Midazolam 0.3mg/kg
6) Pressure (cricoid) - BURP” Backward, Upward, Rightward Pressure
7) Paralysis
IV Succinylcholine 1-1.5mg/kg IV Rocuronium 0.6-1.2mg/kg
8) Placement confirmation
Auscultation, Lung expansion, Spo2

9) Postintubation care
Secure ETT
Initiate mechanical ventilation
Sedation
CXR

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Equipments

1- ETT tube

2- Stylet

3- syringe 10cc

4- Suction catheter

5- Carbon dioxide detector

6- Oral and nasal airways

7- Ambu bag and mask attached to oxygen source

8- Assistant for cricoid pressure

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Indications for intubation

unable to protect airway
inadequate spontaneous ventilation
O2 saturation

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COMA GCS

``` Eyes 1 2 3 4 ``` ``` Verbal 1 2 3 4 5 ``` ``` Motor 1 2 3 4 5 6 ```

COMA Approach

1) ABCs * Airway: take into account: Trauma- C-spine injury, facial trauma, fall/collapse Reversible cause - Hypoglycemia or narcotic overdose Poisoning – eg carbon monoxide

COMA Resuscitation components

1) IV acesss + Blood Ix (DXT, RBS,FBC, RP,LFT, ABG/VBG) 2) ECG 3) Universal Antidotes: IM Thiamine 100mg (alcoholic/cachectic/malnourished), 50% Dextrose 50cc (hypoglycaemia) Naloxone 0.4-2.0mg IV (narcotics overdose)

SHOCK Shock in trauma is HEMORRHAGIC until proven otherswise

See classification

SHOCK Estimation of degree of shock

See table

SEPSIS Diff berween SIRS, sepsis, severe sepsis and septic shock

See image

SEPSIS Organ disfunctions

Organ dysfunction (before fluids resus) - sBP 2 hours - Creatine > 2.0 - INR > 1.5 or aPTT >60s - Plt 20 - Lactate > 2 - Bilateral pulmonary infiltrates

Sepsis bundle To be completed in 3 hours

1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Sepsis bundle To be completed in 6 hours

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7) Remeasure lactate if initial lactate was elevated* *Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.

Sepsis pressors

Sepsis Pressors 1. Noradrenaline Start 0.5-1mcg/min (max 30mcg/min) 2. Vasopressin 0.04units/min 3. Dopamine 2-50mcg/kg/min (normal stable dose 20mcg/kg/min)

Chest trauma

The A & E HO guide

Chest tube insertion

See images

Abdominal pain Ddx

GIT: gastritis, appendicitis, PUD, hepatitis, PUG GUT: UTI, calculi, pyelonephritis Gyn: ectopic pregnancy, PID, endometriosis Vasc: AAA, bowel/splenic infarct Others: DKA, MI , intraab abscess, pneumonia

Abd pain Assessment

Isp: Jaundiced, pallor Ausc: bowel sound, bruits Perc: dullness, PA: tenderness/guarding/rebound epigastric Gastritis/pancreatitis SuprapubicUTI (UFEME-Leu+,Nit+,Hb+) RIF +,Rovsing+appendicitis (WCC raised) Rebound +perforated bowel / PGU Renal punch+pyelonephritis

Abd pain Mx

Ix: FBC/RP/LFT/Amylase/UFEME ECG: TRO MI AXR – calculi, fecal loaded, bowel distension CXR PA erect – Free air, gas pattern USG: free fluid, ectopic preg, biliary colic plan: IV ranitidine 50mg stat Syr MMT 10ml stat * IV Tramal 50mg stat

Fever Dengue fever

Hx: Dengue prone area Warning sx: Decreased Plt + raised HCT Enlarged tender Liver Nausea , persistent Vomiting GIT (abdominal) pain Unrest, lethargy Erythema (gum/mucosa bleeding) Fluid accm (ascites/effusion)

Dengue fever

o/e: Hydration fair Pulse volume good Warm peripheries Tachycardia?

Dengue fever Mx

FBC: Plt + TWC low, HCT raised LFT: elevated liver enzymes (hepatitis) Tx: Hydration as per protocol

Fever Leptospirosis

Hx: Jungle trekking swimming in calm water

Leptospirosis Ix

CK raised > 1000 Leptospirosis RP: deranged  lepto w renal involvement

Leptospirosis

IVD hydration IV Doxycycline 100mg ; or IV Rocephine 2g Lepto IgM / MAT

Malaria

Hx: recent travel foreigners

Malaria Ix

BFMP LFT FBC: +/- Hb drop

Malaria

IV Artesunate IV Primaquin/Chloroquin

Tonsilliopharyngitis

vomiting after eating poor oral intake

Tonsillopharyngitis Ix

Grade I-IIsymptomatic tx Grade III-IVKIV ENT

Tonsillopharyngitis Mx

Syr PCM 15mg/kg, Supp PCM 125mg T PCM 1g QID T Amoxy 500mg / Syr 15mg/kg tds 5/7 Thymol gargle

UTI sx

Dysuria, frequency, cloudy urine, painful urine

UTI Ix

suprapubic pain+ UFEME: Leu+, Nit +, Hb+/-

UTI

T cephalexin 500mg TDS Ural sachet

Abscess / DFU / Cellulitis - DM Sx Ttt

- WI: tender, swollen, warm, fluctuant, pus, foul smelling T Cloxacilin 500mg QID

DKA Effective serum osmolality Total osmolality

Effective serum Osmolality 2(Na +K) + RBS + Urea = > 320mmol/L Total Osmolality 2(Na) + RBS + urea = >330mmol/L Anion gap = Na – (Cl+bicarb)

DKA criteria Ix

Hyperglycemia (>14mmol/L ) + Metabolic Acidosis (pH

DKA regime

1)1 pint NS over 1H, 2H,4H,6H,8H when DXT

HHS

Hyperglycemia >33mmol/L pH >7.3 , Bicarb

IV Digoxin 0.25-0.5g Cardiovert 120 J

VT/Pulseless VF

Continous CPR Shock 200J (B) / 360 J (M) IV Adrenaline 1mg every 2mins IV Amiodarone 300mg bolus (rpt 150mg) or IV Lignocaine 1.5mg/kg (rpt 0.75mg/kg)

SVT

Carotid massage Cardiovert 50 J IV adenosine 6mg / 12mg / 12mg

Indication for cervical collar

N-neurological deficit S-spinal tenderness A-altered mental status I-intoxication (alcohol or drugs) D-distracting pain